Go Retire Psychiatrist

I found another old blog post, Thoughts on Munchausen’s Syndrome, which reminded me of a psychiatric disorder I saw probably more frequently than most psychiatrists unless they are consultation-liaison specialists. I wrote it in June of 2011. I still don’t understand the disorder and I doubt anyone else does either. The interesting connection to Iowa is that a patient with Factitious Disorder was admitted to the University of Iowa Hospital in the 1950s. The treating doctor published a paper about him in the Journal of the American Medical Association.:

“I ran across an old poem written by William Bennett Bean, M.D., who was a physician in the Department of Medicine at the University of Iowa. It’s called “The Munchausen Syndrome” and it was published in 1959 [1]. Dr. Bean was Professor and Chairman of the Department of Medicine at the University of Iowa in 1948. Of course, he did more than write interesting poetry. He specialized in nutrition. He was named the Sir William Osler Professor of Medicine at Iowa in 1970.  He was well-known as a clinician and teacher. He was also called a “masterful teller of tales”, which may explain in part why he wrote “The Munchausen Syndrome.”  One quotation is “The one mark of maturity, especially in a physician, and perhaps it is even rarer in a scientist, is the capacity to deal with uncertainty.”

The poem is about a psychiatric disorder about which there is a great deal of uncertainty, formerly called Munchausen’s Syndrome, now known as Factitious Disorder. It’s based on an actual case of the disorder, an account of which was published in the medical literature [3]. An excerpt from the beginning of the work follows:

THE MUNCHAUSEN SYNDROME

By WILLIAM B. BEAN, M.D.

IOWA CITY, IOWA

The patient who shops around from doctor to doctor, the dowager alert for some new handsome young physician to hear her flatulent and oleagi­nous outpourings, the bewildered neurotic who has had a dozen operations for a thousand misunderstood complaints—these we recognize as interest­ing patients or as nuisances we have to deal with as charitably as we may. They occupy the lower end of the spectrum of humanity with all its in­finitely various people. Nearby reside the malingerer and the deadbeat, a shoplifter of medical aid who escapes just ahead of the policeman. At the frayed end of this spectrum we find a fascinating derelict, human flotsam detached from his moorings, the peripatetic medical vagrant, the itiner­ant fabricator of a nearly perfect facsimile of serious illness—the victim of Munchausen’s syndrome. This is the tale of such a patient. He had our medical department in an uproar off and on for forty days and forty nights. His Odyssey I outline here in verse. I find to my anguish that much of the verse does not scan, some does not rhyme, and all is obscure. I proceed.

THE MUNCHAUSEN SAGA

In the summer of Nineteen and Fifty-four At Iowa City, our hospital door,—

Mecca for hundreds every day—

A merchant seaman came our way—A part time wrestler, in denim jacket

Crashed through the door with a horrible racket,

Two hundred sixty pounds at least,

He was covered with blood like a wounded beast.

Try to excuse the tone of the piece; it was written in another era when a more intolerant attitude toward illness mimicry was viewed as malicious undermining of the physician-patient relationship. In fact, it’s virtually impossible to distinguish Factitious Disorder from Malingering. We think of the former as belonging in the category of mental illness and the latter as, well, not an illness at all, but lying in order to get something or to get out of something. Factitious Disorder is marked by lying as well and some try to make the case that the lying which patients with Factitious Disorder engage in, sometimes called “pseudologia fantastica” or pathologic lying, is somehow different from ordinary lying. According to Bean, it’s like this:

He gave us a history, in elegant diction, Which later we found was all out fiction. Carpenter, wrestler and bosun’s mate And stevedore. He could exaggerate! His body was covered with many a scar He said from surgeons near and far

His appendix went in County Cork A navel hernia in New York.

Once, he declared, in Portland, Maine,

A surgeon stripped out his saphenous vein. Surgical scars above one kidney

Came from an ectomy done in Sidney. Scarred, he was, on his abdomen

From a wreck, he said, when with women roamin.’ Another injury he wouldn’t reveal us

Messed up his left internal malleolus. From time to time, as he wove this story

He boasted of prowess and wealth and glory. By courage he ruled his fellow sailors

But he didn’t say much of his many jailors.

In fact, we understand very little about so-called pathologic lying, though the telling of tales is engaged in not just by psychiatric patients. One of the most fascinating consequences of the frustration physicians feel about Factitious  Disorder was the fraudulent case report about Factitious Munchausen’s Syndrome. The paper was published by a couple of resident physicians in the New England Journal of Medicine and was a spurious account of an emergency room patient named Norman U. Senchbau, who claimed to actually have Munchausen’s Syndrome and who demanded admission to hospital for treatment [2].  He supposedly confessed to having undergone many surgeries and to prove it, displayed many scars on his abdomen…which washed off with soap and water. Of course, the name of the patient is just an anagram of Baron Munchausen.

I occasionally get calls from internists and surgeons about patients whom they suspect of manufacturing illness for the sake of taking the role of patient (part of the definition of the disorder in the Diagnostic and Statistical Manual of Mental Disorders). As often as not, I have no clear idea of how to proceed with interviewing someone who probably does deliberately produce illness, other than to do my best to listen for understanding, to avoid confronting them, and to seek some way to interrupt their self-destructive behavior. In the end I don’t believe we now know much more than Bean did:

What do we know of the pathogenesis

Of hospital vagrants and doctors menaces? Maybe the person acts unenlightened

From a real disease which has him frightened. Does part of the reason he may vex you all Lurk in dark leanings homosexual?

What is the cause, and what are the reasons He wandered pitifully through the seasons? Lonely pilgrim out of orbit

Peace and quiet lost in forfeit.

Hospital haunters, doctor deceivers

Their acting confounds even nonbelievers. Derelicts lost in a cold society

Wanderlusting, without satiety.

Social pariah or medical freak

Whence does he come and what does he seek?

I cannot relieve my brain’s congestion By unveiling an answer to this question In the age of sputniks, the fall of parity We all should try to think with clarity.

L’Envoi

Princes and wise men of many conditions

Beautiful ladies and honored physicians

I’m sorry I cannot fasten my claws in

What causes the Syndrome named Munchausen, This off again, on again, gone again Finnegan

Comes in, than goes out and at length comes in again. Munchausen’s victims must be expected

To plague our lives unless detected.

Those we identify when we sight ’em

Should be restricted ad infinitum

So be alert for this great nonesuchman Munchausen syndrome’s flying Dutchman.

1.    Bean, W.B., The Munchausen syndrome. Perspectives in biology and medicine, 1959. 2(3): p. 347-53.

2.   Gurwith, M. and C. Langston, Factitious Munchausen’s syndrome. The New England journal of medicine, 1980. 302(26): p. 1483-4.

3.   Chapman, J.S., Peregrinating problem patients; Munchausen’s syndrome. Journal of the American Medical Association, 1957. 165(8): p. 927-33.”